Impact of COVID-19 on the Sustainable Development Agenda and Global Kidney Health
Authors: Valerie A. Luyckx, Ziyad Al-Aly
Journal: Journal of the American Society of Nephrology (2023)

The United Nation's 17 Sustainable Development Goals (SDGs) were launched in 2015 aiming for significant progress toward each goal by 2030.1 Many SDGs have direct relevance to kidney health and should concern the kidney community.2 By 2019, some progress had been made.1 However, the coronavirus disease 2019 (COVID-19) pandemic has caused major setbacks risking significant reversal of progress that may also threaten kidney health in the coming years. The most overarching SDG is SDG 1, to end poverty everywhere.1 By 2018, the proportion of people living in extreme poverty (on <$1.90/d) had declined from 36% in 1990% to 8.6%.3 The pandemic reversed this progress, pushing an additional 93 million people into extreme poverty by 2022,1 through loss of employment and work hours in formal and informal sectors and the lack of social safety nets in many places. Although many governments did extend social protections, over 90% were temporary, leaving many unprotected.1 Poverty affects kidney health by increasing the risk of kidney disease through limiting access to healthy food and lifestyle choices, increasing exposure to poor sanitation and unhealthy environments, greater occupational risks, restricting access to health care, and increasing reliance on potentially harmful traditional remedies.2 Poverty exacerbated the risk of severe acute respiratory syndrome coronavirus 2 infection among people with kidney disease, which is often more prevalent among those with lower incomes. People with lower incomes tend to live in overcrowded conditions, rely on public transportation, and are less able to work from home—making them more susceptible to repeated infections and their consequences. Many families will remain in poverty after the pandemic because of loss of full-time employment (125 million full-time jobs lost), the increase in numbers of young people not engaged in school or training, and the slow economic recovery.1 These realities are interrelated with SDG 8 (decent work for all) and SDG 9 (sustainable and resilient infrastructure and innovation). Equity was a major casualty of the COVID-19 pandemic. Gender equity (SDG 5) has worsened. Women and girls had increased hours of unpaid work, pay cuts, dropped out of the labor force, experienced more intimate partner violence, and were at higher risk of child marriage because of the pandemic.1 Even women with education and social status, including those in academic medicine, have been disproportionately affected.4 These gender-linked factors negatively affect maternal health, increasing risk of poor pregnancy outcomes with short- and long-term consequences for maternal and child kidney health and reduce health-seeking possibilities for women in some settings.1 SDG 10 aims to reduce all inequalities. During the pandemic, the average Gini index (measure of income inequality within a country) for emerging market and developing countries increased by 6%.5 Disparities are widening between countries. After a drop in 2020, global manufacturing has begun to rebound, but the recovery is skewed toward high-technology industries and high-income countries.1 The rich have gotten richer and the poor have gotten poorer. Health and well-being (SDG 3) has very obviously been affected by the pandemic. By December 2021, almost six million people were reported to have died of COVID-19; in May 2022, it was estimated that 14.9 million excess deaths occurred directly or indirectly because of the pandemic.1 COVID-19 has amplified inequities in health, with the older people and chronically ill being the most vulnerable and populations in lower resource settings having less access to preventive and therapeutic options.1 People living with end-stage kidney failure have been particularly affected because of their increased risk of infection, severe illness and death, as well as lockdowns and curfews which reduced access to dialysis and/or transplantation. People living with chronic kidney disease likely experienced disruptions in care. Chronic weaknesses in health systems became glaringly evident, with erratic access to testing and personal protective equipment which affected patients and staff in dialysis units, more so in lower compared with higher resource settings.6 Stalled or reversed progress in other SDGs will affect kidney health over the coming years. Global (mal)nutrition (SDG 2) has escalated, with an additional 150 million people facing hunger.1 Food insecurity and obesity both increased among children associated with lockdowns and school closures. Over 370 million children missed school meals during the pandemic, for many their only source of a balanced meal.7 Nutrition is key for healthy pregnancies and healthy lifestyles to reduce kidney disease risk and in the management of advanced kidney disease to delay progression and manage complications. Gains were lost in improving access to quality education (SDG 4), with an additional 10% of children between grades 1 and 8 falling below minimum reading proficiency levels in 2020.1 As of January 2022, over 600 million students remained affected by school closures.7 Loss of education not only affects future (kidney) health and health literacy but will affect future earning potential and family structure.1 Billions of people worldwide still lack access to safe water and sanitation (SDG 6), which meant fewer opportunities to maintain (hand) hygiene in homes, schools, and health facilities and persistent risk of infections and acute kidney injury.1 The health workforce has been significantly affected by the pandemic. By May 2021, between 115,000 and 180,000 health care workers had likely died of COVID-19.8 Many more have been infected, some in the line of duty, especially where personal protective equipment and vaccines access were suboptimal.6 Physical and moral distress have been high among health workers, in part because of work circumstances but also because of pressures imposed by family needs, fear of infecting family members, overwork in compensating for absences of colleagues due to illness, etc. The pandemic has had a devastating effect on many lives and livelihoods, but it can also become a catalyst for change. We must develop strategies to build back better on many levels. The world must indeed focus on prevention and treatment of infections, but the pandemic has highlighted the great cost of the decades of having overlooked the needs and vulnerabilities of people living with noncommunicable diseases. Glaring social and structural inequities exposed by COVID-19, coinciding with the Black Lives Matters and Decolonizing Global Health movements, have led to calls for reckoning and change in national and international policies.9 These calls question the meaning of intellectual property when lives are urgently at stake, the benefits and harms imposed by international trade agreements and the benefits and harms of nationalism.9 They highlight the need to urgently address social injustice and achieve social transformation, to change education (medical) curricula, and to be conscious of and curb explicit and implicit bias in life and work—especially within health systems—and have initiated debate around the ethics of moral responsibility, reparation, triage, rationing, and the need for global solidarity.9 A new sense of urgency has arisen around climate change (SDG 13), with the recognition that cooperation and innovation are required, globally, to address this threat. Healthier environments could reduce global deaths by 23%.10 Sustainability and resilience must be at the core of strategies to curb climate change, foster recovery, and initiate rehabilitation of the environment. SDG 16 and 17 emphasize the need for "peace, justice, and strong institutions"1 and the need for partnerships to achieve the SDGs. These are the key goals to operationalize the achievement of all the others. The tragic invasion of Ukraine by Russia so close on the heels of the pandemic risks further destabilizing the global food supply, oil markets, and economic stability which will disproportionately affect vulnerable and marginalized populations worldwide. People with kidney disease and especially those with kidney failure living on dialysis are particularly vulnerable in war, given disruptions in access to dialysis with destruction of infrastructure, forced displacement, food and medication insecurities, and patient frailty. As we again observe COVID numbers surging in China, many questions arise regarding the effect this will have on China itself, the risks of potential new variants, and the ripple effects on the global economy and health indicators. COVID-19 has illustrated that good health cannot be achieved within the silo of the health system and that health can be threatened by factors independent of the health system. The community of nephrologists and our allies must leverage this moment to regain momentum toward progress on SDGs (Table 1). We owe it to our patients and our communities, and the world will be better for it. Table 1 - Awakenings and actions arising from the pandemic1 Awakening Most Relevant SDGs Actions Needed Recognition of the need for global solidarity across all sectors SDG 16—peace, justice, and strong institutionsSDG 17—partnerships for the goals Multisectoral action to achieve SDGs everywhereReview intellectual propertyReview international trade agreementsFocus on fair pricing and fair profitsReduce country nationalismCurb fake newsRegain trust of the population in decision makersReduce conflicts, wars Inequities can no longer be ignored SDG 1—no povertySDG 3—good health and well-beingSDG 4—quality educationSDG 5—gender equalitySDG 8—decent work and economic growthSDG 10—reduced inequalities Access to health care services, technologies, productsStructural violenceGenderAgeXenophobiaRacismGeographyPovertyEducation Climate change requires urgent action SDG 6—clean water and sanitationSDG 7—affordable and clean energySDG 9—industry, innovation, and infrastructureSDG 11—sustainable cities and communitiesSDG 12—responsible consumption and productionSDG 13—climate actionSDG 14—life below waterSDG 15—life on land ResilienceSustainabilityInnovationGreen health care deliveryProtect the environment Do not leave noncommunicable diseases behind SDG 2—zero hungerSDG 3—good health and well-beingSDG 8—decent work and economic growthSDG 10—reduce inequalities Promote prevention across life spanStrengthen health system resilienceEnsure availability of essential diagnosticsEnsure availability of essential medicinesEnsure consistent quality careRecognize vulnerabilities SDG, Sustainable Development Goal.